National Diabetes Inpatient Audit 2019 Data Quality Statement

Published 13 November 2020

## Contents

| Section | Page | |------------------------------------------------------------------------|------| | Introduction | 3 | | Relevance | 3 | | Data collection | 3 | | Inclusion criteria | 4 | | Timeliness and Punctuality | 4 | | Accuracy, Reliability and Limitations | 4 | | Coherence and Comparability | 5 | | Comparability over time | 5 | | Comparability with other sources | 6 | | Confidentiality, Transparency and Security | 7 | | Accessibility and Clarity | 7 | | Assessment of User Needs and Burden on respondents | 7 | | Providing feedback | 8 | Introduction

The National Diabetes Inpatient Audit (NaDIA) audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).

The 2019 NaDIA report is the ninth annual snapshot audit of diabetes inpatient care in England and Wales. The audit is open to participation from hospitals with medical, surgical, gynaecology wards or intensive care units.

NaDIA 2019 was a repeat of the 2010 to 2013 and 2015 to 2017 collections. There was no 2014 audit and NaDIA 2018 covered the hospital characteristics only. Wales did not participate in NaDIA 2019, though Welsh organisations have participated in six previous full NaDIA collections: 2011 to 2013 and 2015 to 2017, plus the 2018 hospital characteristics collection.

The audit sets out to measure the quality of diabetes care provided to people with diabetes while they are admitted to hospital, by answering the following questions:

- Did diabetes management minimise the risk of avoidable complications?
- Did harm result from the inpatient stay?
- Was patient experience of the inpatient stay favourable?
- Has the quality of care and patient feedback changed since NaDIA 2010, 2011, 2012, 2013, 2015, 2016 and 2017?

The report will be of interest to the public, especially to people with diabetes. Health planners and policy makers, as well as acute NHS Trusts, Clinical Commissioning Groups (CCGs), Local Health Boards (LHBs), Sustainability and Transformation Partnerships (STPs), Clinical Networks (CNs; formerly Strategic Clinical Networks or SCNs) and other providers and commissioners of specialist diabetes services will also make use of the information in this report.

The report presents findings from the 2019 audit – carried out on a day between 23 and 27 September 2019 – on patients admitted for at least 24 hours to specified types of inpatient ward (see inclusion criteria below). The audit collected data on characteristics of the hospital, patient clinical data and the patient experience using paper-based questionnaires and an electronic data collection tool. Because Wales did not participate in NaDIA 2019, combined England and Wales data from earlier NaDIA collections has been re-analysed to include English NaDIA sites only.

NaDIA is the companion audit to the continuous NaDIA-Harms collection of diabetic inpatient harms in England, which has been undertaken since May 2018. The 2019 NaDIA-Harms report is published here: http://digital.nhs.uk/pubs/nadia-harms2019.

Relevance

Data collection

The National Diabetes Inpatient Audit 2019 was carried out by hospital teams in England on a nominated day between 23 and 27 September 2019. The teams collected patient clinical data and patient experience information using paper-based questionnaires, which were collated into patient-level csv files for analysis. Data on characteristics of the hospital including staffing structures were collected using an electronic data collection form submitted to the NHS Digital Strategic Data Collection Service (SDCS) https://datacollection.sdcs.digital.nhs.uk/.

Each participating hospital identified eligible inpatients with diabetes (see inclusion criteria below) and distributed questionnaires. Where the patient was able and willing, a Patient Experience form was completed alongside a Bedside Audit form providing information on the patient's medical treatment. If required, the patient was able to complete and return the Patient Experience questionnaire at a later time. The hospital team also completed a Hospital Characteristics questionnaire providing information on the hospital's resources and staffing structure. Sample copies of the 2019 questionnaires can be found on the NHS Digital website: http://digital.nhs.uk/diabetesinpatientaudit.

**Inclusion criteria**

A patient was included in the inpatient audit if they had been admitted to a hospital bed for 24 hours or more. Patients on an Obstetric or Paediatric ward were excluded from this audit. Mental Health hospitals were also excluded due to the high prevalence of long stay patients. Other exclusions included:

- Patients who were hyperglycaemic but not yet formally diagnosed with diabetes
- Accident and Emergency
- Day case ward
- Day surgery unit patients
- Observation ward (if patients had been admitted for less than 24 hours)
- Surgical short stay unit (if patients had been admitted for less than 24 hours)
- Palliative care centres
- Community hospitals.

**Timeliness and Punctuality**

Sites participated in the audit between 23 and 27 September 2019. Paper questionnaires (the Bedside Audit and Patient Experience) were returned by 11 October 2019 (extended to 18 October 2019 for some sites) and the Hospital Characteristics electronic questionnaires were returned by 18 October 2019 (extended to 1 November 2019 for some sites). Publication was scheduled for 14 May 2020, but was delayed due to the COVID-19 pandemic. The local and national level NaDIA 2019 reports were published on 13 November 2020. The time lag to the publication of the main report is therefore fourteen months after organisations conducted the survey.

**Accuracy, Reliability and Limitations**

Participation in terms of the number of patients reported on has increased slightly since the 2017 audit (14,891 English patients in 2017 and 15,479 in 2019). The data returned to NHS Digital underwent data cleaning and mapping of responses to previous audit questions in order to enable as much comparison as possible to earlier audit years.

Participation in the audit is voluntary, but encouraged, for all hospitals with inpatient beds meeting the inclusion criteria. 188 hospital sites in England (from 130 NHS trusts) took part in the 2019 audit, assessing the clinical care of 15,479 patients. In comparison, the previous audit in 2017 collected data from 190 hospital sites (from 134 NHS trusts) on 14,891 inpatients in England with diabetes. The audit does not collect data from outside England and Wales.

Local results in NaDIA are published at hospital site level. A NaDIA ‘hospital site’ may represent a single hospital, multiple hospitals or an entire NHS Trust. Because NaDIA hospital site aggregations vary over time, year-on-year changes in participating hospital sites may not represent real changes in participation.

Wales did not participate in NaDIA 2019, though Welsh organisations have participated in six previous full NaDIA collections: 2011 to 2013 and 2015 to 2017, plus the 2018 hospital characteristics collection. For the 2019 report, combined England and Wales data from earlier NaDIA collections has been re-analysed to include English NaDIA sites only.

There is not a definitive figure for the expected prevalence of people with diabetes amongst people admitted as inpatients.

Due to time and resource constraints, hospitals may not have been able to complete forms for all eligible audit patients.

A survey was not required to have every question completed in order to be included in the audit analysis, and completion rates varied between the different questions in the survey.

Patient Experience surveys are only completed by those patients who were willing and able to do so, either at the time of the Bedside Audit or returned later by mail. 8,664 inpatients responded to the patient experience element of the audit out of the total responses to the audit (15,479 patients), a response rate of 56.0 per cent. Weighting has already been applied to the Patient Experience results to reflect the differing response rates by age, ethnic group, type of admission, type and duration of diabetes, ward speciality and length of hospital stay at the time of the audit. The weights are calculated using the relative proportions of the eligible population, the Bedside Audit respondents.

Patients that did not want information related to them to be included in the audit could choose not to be included by informing the person carrying out the survey. None of their information was then collected. The number of patients who have chosen not to participate in the audit is not known.

Coherence and Comparability

Comparability over time

This report is the ninth NaDIA. The audit took place previously in 2010, 2011, 2012, 2013, 2015, 2016, 2017 and 2018. There was no audit collection in 2014. Sites in Wales did not take part in the 2010 and 2019 audit. Because 2018 was a NaDIA Quality Improvement Collaborative year, only the Hospital Characteristics survey was undertaken.

As noted in the ‘Limitations of data collection’ section above, Wales did not participate in NaDIA 2019 and combined England and Wales analysis from earlier collections has been reanalysed to contain English hospitals only. Some questions in the audit have changed over time. Comparisons have been made where there was enough consistency in the questions for a comparison to be meaningful, with variation in the question between audit years noted in the report.

**Comparability with other sources**

No other data source provides an equivalent snapshot of the inpatient care of people with diabetes in England and Wales. Most NaDIA data items are unique to the NaDIA collection. Other similar (but not directly comparable) data sources include:

- The National Diabetes Inpatient Audit – Harms (NaDIA-Harms) is a continuous data collection which collects data on occurrences of the following serious inpatient harms that can affect people with diabetes:

  - hypoglycaemia requiring rescue treatment
  - diabetic ketoacidosis (DKA)
  - hyperglycaemic hyperosmolar state (HHS)
  - new diabetic foot ulceration (DFU)

  Data on all four inpatient harms is also collected in the annual NaDIA snapshot collection.

  The 2019 NaDIA snapshot figures have been adjusted for comparison against the number of cases in NaDIA-Harms. The 2019 NaDIA-Harms reported that estimated case ascertainment in the 2019 NaDIA-Harms ranges from 6 per cent (diabetic foot ulcer) to 20 per cent (DKA). The latest NaDIA-Harms report was published on the 13 November 2020 and is available here: [http://digital.nhs.uk/pubs/nadia-harms2019](http://digital.nhs.uk/pubs/nadia-harms2019).

- The core National Diabetes Audit (NDA) collects data on patient demographics, care processes and treatment targets amongst those registered with participating GP practices and secondary care organisations in England and Wales. The majority of core NDA data is from primary care: 98.3 per cent of patients in the 2017-2018 NDA (covering 1 January 2017 to 31 March 2018) were from primary care records. 98.0 per cent of general practices in England and Wales have participated in the latest published core NDA (2018-2019 NDA, covering 1 January 2018 to 31 March 2019). Inpatients in the September 2019 NaDIA snapshot may be included in the core 2018-2019 NDA cohort if they were diagnosed with diabetes during or before the NDA collection period and their data was submitted to NDA by a participating GP practice or secondary care organisation.

- Hospital Episode Statistics (HES) and Patient Episode Database for Wales (PEDW) databases containing details of all admissions, outpatient appointments and Accident and Emergency attendances at NHS hospitals in England (HES) and Wales (PEDW). Inpatients in the September 2019 NaDIA snapshot are included in the HES or PEDW admitted patient care (APC) databases. Although HES and PEDW contain an extensive range of data items (see the HES Data Dictionary and the NHS Wales Data Dictionary), almost all non-demographic data items in NaDIA are unique to the NaDIA collection.

Patient identifiers are not collected in NaDIA, so direct linkage to other data sources is not possible. Confidentiality, Transparency and Security

Audit information is held securely and with restricted access. No patient identifiable information (e.g. NHS number, date of birth) is collected by the audit. Audit data may be released to researchers with formal research approval for work related to the improvement of care for people with diabetes: http://digital.nhs.uk/DARS

All patients may choose not to take part at the time the audit is conducted. Patients are provided with a Patient Information Leaflet for NaDIA which informs them of this option. The leaflet is available from the NHS Digital website: https://digital.nhs.uk/binaries/content/assets/legacy/pdf/c/9/2017nadia_patient_leaflet_v4.pdf

It is expected that, through the audit collection, all organisations will continue to follow existing NHS codes of practice in regard to patient confidentiality, information security management, record management and other legal obligations.

A risk assessment has been carried out on the audit publication, and suppression has been applied at hospital site level in order to protect patient confidentiality when the number of diabetes inpatients reported by an organisation was low. At hospital site level, organisations with 5 or fewer diabetes patients (based on the number of Bedside Audit returns) will be suppressed. The total number of hospital beds will be retained (taken from the Hospital Characteristics form), but all other values will be asterisked. Hospital site level outputs will not be shown if the denominator is less than 10.

In line with the government transparency agenda, NHS Digital provides hospital site level data taken from the audit, in CSV format, as part of the audit publication available through the NHS Digital website, and also through the UK open data portal, data.gov.uk.

Accessibility and Clarity

The main report is presented in both PowerPoint and PDF formats on the NHS Digital website, with the hospital site-level reports and supporting data accompanying the report provided as Excel spreadsheets. CSV files are provided for the backing data of all hospital site level reports. A CSV of data from English organisations at site level is available on the NHS Digital website and through http://data.gov.uk. All the above reports are available on the NHS Digital website at: http://digital.nhs.uk/pubs/nadia2019.

More information on the methodology used to create the report can be found in the Methodology document and the ‘overview’ sections present throughout the body of the main report.

Further information about the audit may be found at: http://digital.nhs.uk/diabetesinpatientaudit.

Assessment of User Needs and Burden on respondents

The NaDIA advisory group (consisting of patient representatives, healthcare professionals, administrators, researchers and analysts, including representation from Diabetes UK, NHS Digital and Public Health England (PHE)) provide advice on the content of the reports as well as the direction and development of the audit. The wider National Diabetes Audit (NDA) team has an active role in the National Cardiovascular Intelligence Network (NCVIN) workshops to gain a better understanding of how CCG’s and localities use the data and how we can improve the NDA programme’s publications and supporting information. These workshops are conducted quarterly and are co-ordinated by PHE and bring together epidemiologists, analysts, clinicians and patient representatives.

The survey questionnaires are reviewed and amended prior to the running of each audit in order to ensure the necessary information is collected with the least burden on audit participants (organisations and patients).

The audit team acknowledges that participation in the audit involves costs in both time and organisation for the patients and providers that take part, and thanks them for their efforts. The audit continues to look at ways in which to reduce respondent burden and increase ease of participation, and welcomes comments and suggestions.

**Providing feedback**

NHS Digital is keen to gain a better understanding of the users of this publication and their needs, as well as welcome suggestions on how to decrease respondent burden.

Your feedback is welcome and may be sent to enquiries@nhsdigital.nhs.uk. Please include ‘National Diabetes Inpatient Audit’ in the subject line.

Alternatively, you can call our contact centre on 0300 303 5678

Or write to:

NHS Digital, 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE. Information and technology for better health and care

www.digital.nhs.uk 0300 303 5678 enquiries@nhsdigital.nhs.uk @nhsdigital

This publication may be requested in large print or other formats.

Published by NHS Digital, part of the Government Statistical Service

Copyright © 2020 Health and Social Care Information Centre The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital.

OGL

You may re-use this document/publication (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0.

To view this licence visit www.nationalarchives.gov.uk/doc/open-government-licence or write to the Information Policy Team, The National Archives, Kew, Richmond, Surrey, TW9 4DU; or email: psi@nationalarchives.gsi.gov.uk